F0804

D

Failure to Maintain Safe and Palatable Food Temperatures During Meal Service

West Bend, Wisconsin Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that meals were served at a palatable and safe temperature, as required by its Safe Food Handling policy and the FDA Food Code. The policy directed dining services staff to use food preparation techniques that minimize the time food is held below 135°F or above 41°F. During a meal service observation, dietary staff initially measured appropriate temperatures in the kitchen for the regular diet entrée of chicken fried steak (164°F), cheesy rice (160°F), and spinach with onions (167°F) before service. However, residents eating in the dining room were served first, and trays for residents who chose to eat in their rooms were plated afterward, with the last cart not reaching the fourth floor until later in the meal period. The cart door remained open while trays were passed, and the last tray was not served until 12:45 PM.

Two cognitively intact residents reported receiving food that was not hot. One resident, admitted on a recent date with an admission MDS showing a BIMS score of 15/15, stated that their bite-sized food “could be hotter.” Another resident, with an admission MDS BIMS score of 14/15, reported that their regular diet meal was cold and that it was always cold. Resident Council minutes documented complaints of cold food at meetings held on two separate dates. A test tray taken from the last cart on the fourth floor and checked with a digital thermometer by an RN showed the chicken fried steak with gravy at 126°F, cheesy rice at 130°F, and spinach with onions at 130°F, all below the 135°F standard for food service and palatability. These observations and interviews demonstrate that the facility did not consistently maintain food temperatures during tray line and delivery to residents, resulting in meals being served below required temperatures.